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Back in the field

Summer 2016

After nine years of struggling with constant discomfort and no clear diagnosis, Elaine Fisher finally feels at peace. A Canadian first in robotic surgery has allowed her to regain control over her life, and the memories of being confined to her house are fading away.

Elaine’s symptoms began in 2006. She experienced abdominal cramping and bloating several times a day, and was increasingly unable to control bowel movements. As a farmer and a mother of four busy kids, the symptoms were disruptive and soon became debilitating at their worst.

Elaine and her husband Mark are the primary workers on their family’s beef and dairy farm in Ayton, Ont. Their farm houses 50 dairy and 30 beef cows at any given time, and produces a number of cash crops. Indeed, it is a busy yet rewarding lifestyle requiring continuous work. Sadly, as Elaine’s symptoms became more frequent, bending, lifting, and even laughing became activities of the past.

“My son’s hockey team won a regional championship, and I couldn’t get excited along with the rest of the crowd,” she says. “I had to sit there and control my emotions so that I wouldn’t have to run to the bathroom.”

As Elaine’s condition worsened, her ability to contribute on the farm became extremely limited.

“In the first few years of having symptoms, there were days where I could go out and function,” says Elaine. “But in the last couple years, the cramping, pain and discomfort was so severe. I did what I could, but I could not help in the ways I wanted to.”

Elaine also experienced emotional effects from the constant discomfort. “It definitely led to depression,” she shares. “There were days where all I wanted to do was go to bed. The last thing I wanted was to have an accident in public. If I didn’t absolutely have to leave the house, I didn’t.”

A tricky diagnosis

When Elaine sought medical attention it made sense to explore hereditary conditions in her family that might have explained her symptoms. Her mother suffers from Crohn’s disease, and one of her daughters has Celiac disease.

“I was desperate to find out what was wrong, so I tried different treatments over the years,” she says. “I went on medications and changed to a gluten free diet, but nothing helped.”

In 2015, Elaine’s family doctor suspected that her symptoms were the result of an entirely different condition – obstructive defecation syndrome (ODS). ODS is caused by a physiological change that creates an empty space beside the rectum which can shift and physically block the emptying of the bowel.

“Women are more prone to developing ODS because of childbearing,” says Dr. Alkhamesi. “As the muscles in the pelvic floor weaken, the rectum gets wider. So there is a chance for bowels to spill into that space. As a result, patients either constantly strain to empty the bowel, or they have no control over when the bowel empties.”

A series of tests determine if a patient has ODS. While Elaine had undergone some of the necessary tests previously, they were not done in the sequence or time frame which would have led to an ODS diagnosis.

“I was so thankful that I finally knew what was wrong and that it wasn’t all in my head,” says Elaine. “Things were not going well, and something had to be done. To have a diagnosis was a huge relief.”

Minor treatments such as dietary changes, laxatives, and exercise can help curb symptoms in the majority of patients with ODS. But in a severe case like Elaine’s, surgery was necessary.

“It’s a very big surgery,” says Dr. Alkhamesi. “We insert a biological mesh that the body absorbs in order to strengthen the walls of the rectum. But that isn’t the extent of it. The body’s organs have moved and need to be repositioned.”

A Canadian surgical first

Thankfully, Dr. Alkhamesi knew of a minimally invasive approach to the procedure from his training in the United Kingdom which utilized a robotic surgical system. While the surgery had never been performed in Canada, it had shown success in parts of Europe. With the prospect of avoiding a large abdominal incision, he was eager to provide the option to Elaine.

“It was a bit daunting to know that the surgery was so new,” says Elaine. “Dr. Alkhamesi was very good at explaining what had to be done. I was confident going into the surgery.”

The robotic procedure involves three or four small incisions. Additionally, the robot allows access to deep, limited spaces in the body, and avoids the need to cut through muscles. The traditional procedure required patients to spend seven to 10 days in hospital recovering. With the robotic procedure, Elaine was walking around with the help of nursing staff within three hours of the surgery and returned home the next day.

Life after surgery

The discomfort Elaine spent nine years coping with has disappeared. She is no longer fearful of going out in public, and does not have to think about where a bathroom is located every time she leaves the house.

These days, Elaine frequently volunteers at her kids’ schools and accompanies them on class trips. She can be found cheering on her sons at their sporting events, and watching proudly as her daughters participate in horseback riding competitions.

“Patients who have had this surgery talk about how their lives change from being consumed with what we take for granted,” says Dr. Alkhamesi. “This is an operation that improves quality of life.”

Approximately 30 per cent of patients referred to Dr. Alkhamesi experience symptoms like Elaine’s due to a cancerous growth. Elaine urges anyone who has similar symptoms to get the help they need – to avoid the emotional and physical toll that ODS took on her life, and to determine whether symptoms are the result of a more serious condition.

“People might hesitate to see a specialist and think it may go away on its own. You need to be persistent with it,” says Elaine. “This is a sensitive topic, and people might struggle with talking about it. But it is not worth keeping quiet about.”

Signs of obstructive defecation syndrome (ODS) include unsuccessful attempts to empty the bowel, excessive straining, involuntary evacuation of the bowel, pain in the rectum, stomach cramping and bloating, bleeding after defecation and a sense of incomplete defecation despite repeated attempts. Difficulties with bowel function are extremely common, but only around 20 per cent of patients with symptoms will be diagnosed with ODS, and around 10 per cent will be treated with surgery. It is recommended that people who experience disruptions to normal bowel function keep a detailed account of their symptoms and seek medical attention to determine underlying causes.

Donors make a difference

Historically, donors to London Health Sciences Foundation have played a critical role in funding the surgical robots at London Health Sciences Centre (LHSC) – from the original, single-arm AESOP and the three-armed ZEUS right through to the last-generation da Vinci surgical robot.

Now, donors are continuing to play an important role in helping patients and families by funding LHSC’s next-generation da Vinci Si HD surgical systems. On Apr. 12, 2016, London’s Crich family, owners of the Auburn Group of Companies, continued the proud tradition with a $1 million gift in support of LHSC’s robotic surgery program.

"Because our family has been touched by the wonderful caregivers at London Health Sciences Centre, most particularly Dr. Bob Kiaii and Dr. Neil McKenzie, we are making a commitment today to ensure that patients will continue to experience the exemplary care made possible when skilled and caring surgeons have access to the latest and most innovative technology," said Jamie Crich.